HIPAA Policy

Notice of Privacy Practices for Your Protected Health Information

THIS SUMMARY NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect our legal obligation by the federal Health Insurance Portability and Accountability Act (HIPAA) to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice which describes how Ankeny Family Vision Center protects your health information.

This notice also describes your rights to access and control your protected health information in some cases. Your "protected health information" means any written and verbal health information about you, including demographic data that can be used to identify you. This is health information that is created in or received by Ankeny Family Vision Center, and that relates to your past, present or future physical health or condition.

Prior to receiving any health care services from Ankeny Family Vision Center, we will ask you to sign a one time HIPAA consent permitting Ankeny Family Vision Center, its doctors and staff to use and disclose your protected health information for the purposes of Treatment, Payment, and Health Care Operations. A summary description of these uses is following. We are allowed by law to refuse to treat you if you do not sign the consent form.

(The entire version of this notice is available for you within the office of Ankeny Family Vision Center.)

Right to Notice

As a patient of Ankeny Family Vision Center, you have the right to adequate notice of the uses and disclosures of your protected health information. Under HIPAA, we may use and disclose your protected health information for treatment, payment, and other health care operations.

• Treatment - We may use or disclose your protected health information to a physician or other healthcare provider providing treatment to you, and other purposes described in our full notice.
• Payment - We may use and disclose your protected health information to obtain payment for services we provide you, and other purposes described in our full notice.
• Health Care Operations -We may use and disclose your protected health information in connection with our health care operations. These are described in our full notice.

Uses and Disclosures for Other Reasons without Permission

Ankeny Family Vision Center may use or disclose your protected health information for the following reasons without permission from you:

• Emergency Situations
• Abuse or Neglect
• National Security
• When required by Law
• Communication Barriers
• Workmen's Compensation
• Incidental Disclosures
• Appointment Reminders
• Legal Proceedings
• With Business Associates

(These reasons are explained in more detail in our full notice.)

Your Rights as a Patient of Ankeny Family Vision Center

You have the right to restrict the disclosure of your protected health information with your written authorization unless otherwise permitted or required by law as described above and in our full notice. You may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on the use or disclosure indicated on the authorization.

• You have the right to receive confidential communications regarding your protected health information.
• You have the right to inspect and obtain a copy of your protected health information.
• You have the right to amend your protected health information.
• You have the right to receive an account of disclosures of your protected health information.
• You have the right to obtain a paper copy of this notice of privacy practices from Ankeny Family Vision Center.
• You have the right to request someone act on your behalf.
• You have the right to request a restriction on uses and disclosures of your protected health information.
• You have the right to register a complaint.

(All of your rights are explained in more detail in our full notice.)

Health Information that is Protected

Examples of protected health information are:

• Information regarding your health condition
• Information regarding health care services you have received or may receive in the future
• Information regarding health care benefits under an insurance plan
• Geographic information
• Demographic information
• Unique numbers that may identify you
• Other types of information that may identify who you are

(These examples are explained in more detail in our full notice.)

Changes of Notice and Legal Requirements

Ankeny Family Vision Center reserves the right to change this notice and to make the revised or changed notice effective for protected health information we have already obtained that applies to you as well as any information we may generate in the future. We are required by law to abide by the terms of this notice as it is currently stated. The policies in any new notice will not be in effect until they are posted in our office and a summary posted to this website. You are entitled to obtain your own copy of the revised notice currently in effect.

Contact Information

For further information regarding Ankeny Family Vision Center's privacy policies, please contact our office: Ankeny Family Vision Center 311 N Ankeny Blvd Ankeny Iowa 50023 Phone: 515.964.1671 Fax: 515.964.1714 email: This email address is being protected from spambots. You need JavaScript enabled to view it.